Could your approach to euthanasia be the death of your practice?

The most troubling euthanasia cases typically concern client reluctance to consent to urgently needed euthanasia or requests to euthanise healthy animals for apparently trivial reasons (Batchelor and McKeegan, 2012; Avery, 2013).

Here, the author outlines the context of these difficulties and proposes in-house guidelines can be a useful tool in helping practices allay disagreements about euthanasia.

Background

When the need for euthanasia is disputed, other factors may compound the difficulties:

• The conversation was not predicted by the vet and/or client.
• The allotted time is insufficient to discuss it.
• Generally, an informed opinion that an animal’s life is no longer worth living requires knowledge of what makes life worthwhile to them. If the vet does not first ascertain this, and recommends euthanasia based on clinical facts alone, some owners will disagree, rightly and understandably.
• Euthanasia is not an act of veterinary surgery (RCVS, 2012).

Few owners seem to seek non-veterinary euthanasia, and we are arguably not responsible for such a death if it was impossible for us to affect (Yeates 2009). Yet our natural concern remains – if we refuse euthanasia, a client may pursue an alternative that causes their animal to suffer. Thus, we may agree to euthanise healthy animals for trivial reasons – and suffer nagging regret.

Unlike many human hospitals, practices don’t have clinical ethics committees to provide guidance. Consequently, many vets take an ad hoc approach to troubling euthanasia cases, relying on some combination of:

• their experience and personal values
• the approaches modelled to them during training
• case discussions (for example, those in In Practice)
• RCVS guidelines

The problem

The above normative approach is, largely, a layperson’s approach – due to lack of training historically and the ongoing lack of mainstream CPD. Although euthanasia is the final common pathway of many clinical conditions that are repeatedly covered in CPD, and veterinary well-being is likewise becoming a common topic, neither stream typically offers delegates much help with the nitty gritty of end-of-life decision making and related ethics and communication.

The results of this collective oversight can be undesirable, for our patients, our clients and ourselves:

• For patients. Untimely deaths and/or avoidable suffering, due to euthanasia being either premature or wrongly delayed.
• For clients. Clients have a legitimate interest in having peace of mind about their euthanasia decision. However, approximately 30% of bereaved owners may be haunted by their euthanasia decision (Dawson and Campbell, 2009; Rémillard, 2014). Although animal welfare is the vet’s primary consideration, to ignore the client’s interest arguably falls short of our professional obligation to treat our clients fairly (RCVS, 2012). In comparable cases in human medicine (for example, discussing treatment withdrawal from a terminally ill child), doctors’ knowledge of psychosocial factors and evidence-based communication typically improves peace of mind for all concerned (Truog et al, 2006).
• For veterinary professionals. Our primary aim is to preserve life, while allowing for the mentational limits of our patients. Yet we are also obliged to seek an end to our patients’ lives – typically when certain, usually uncontrollable, suffering exists or is in immediate prospect. Euthanising our patients in these, or more contentious, circumstances creates understandable distress for a significant minority of us (Rohlf and Bennett, 2005; Rollin, 2011).

The aforementioned problems might be minimised through use of compassionate, but clear, in-practice guidelines, to which we and our clients might turn in cases of disagreement. Various bodies offer general guidance (BVA, 2009; RCVS, 2012; BSAVA, 2013). However, it is impossible – and not their purpose – for these to specify the communication needed to reach consensus with each client. Also, they say little about how best to consider a client’s interests. Thus, they are removed from the reality of our individual consulting rooms and, in my experience, cannot help in the immediacy and particularity of each case.

Developing guidelines

The killing of our patients for the right reasons is part of our professional privilege and related position of high public trust. To have practice guidelines on end-of-life accords with that trust and shows leadership to our teams and our clients. Moreover, most practices already state their values. It is, therefore, also reasonable to specify practice guidelines on euthanasia.

The guidelines would help vets and owners make the best choice in difficult end-of-life circumstances.

As with the wider societal ethic for humans (Rollin, 2009), the guidelines would probably rest on several ethical cornerstones, such as:

• inherent value of individuals (rights ethics)
• maximising the common good (outcome-based ethics – utilitarianism)
• what a “virtuous” vet would do (virtue ethics)
• natural sympathy (care ethics; Schneider, 2001)

A draft might be reviewed by clients – to identify any undue paternalism and to check readability – and should be double-checked with the RCVS and the indemnity body.

Considerations

• The client has to live with the death or other loss of his or her animal in ways we don’t. Owners have a legitimate interest in knowing they have made the right decision.
• As compassionate professionals (virtue ethics) and in accordance with RCVS guidelines (RCVS, 2012), we should seek to genuinely understand our client’s position, especially in cases of disagreement.
• It is unlikely animals “can grasp the notion of extended life or choose to trade current suffering for it” (Rollin, 2011). This is because they lack language and thus cannot transcend their circumstances through thought (Rollin, 2011; Dawkins, 2014).
• Suffering is worse than death when there is no effective palliation or cure now or in future, or when the suffering cannot be transcended.
• Animals have intrinsic value independent of external factors such as their purchase price or their caregivers’ feelings towards them. This follows from scientific evidence of animals’ sentience, cognition, personality and social behaviour. Moreover, companion animals are subjects of special partiality (Rollin, 2005), being largely seen as family members. Consequently, a client’s preferences, however understandable, cannot easily be said to trump:
  • healthy animals’ fundamental interest in being alive (rights ethics)
  • a suffering animal’s fundamental interest in having relief (rights ethics, care ethics)
  • an incapacitated animal’s fundamental interest in not, normally, having to remain alive – albeit painlessly – if it will be unable ever again to enjoy the benefits of its continuing existence. This point is key in balancing the difficult situation where their owners are struggling to muster the undoubted courage needed to say goodbye (rights ethics, care ethics).